COLUMBIA COUNTY SHERIFF S DEPARTMENT ELECTRONIC MONITORING PROGRAM RULES/REGULATIONS
|
|
- Patience Willis
- 6 years ago
- Views:
Transcription
1 COLUMBIA COUNTY SHERIFF S DEPARTMENT RULES/REGULATIONS Inmate Name: File Number: 1. You are responsible for all of the applicable rules as established for the Columbia County Huber Facility as well as specific rules for the Electronic Monitoring Program. You will follow all established home, work, etc rules. Unauthorized deviation from your schedule and/or approved travel routes is a violation. 2. You shall comply with all verbal and written instructions from the Jail Staff. 3. You shall remain at your approved residence at all times unless you have specific Security Staff authorization to leave. 4. You shall have a permanent residence in Columbia County unless otherwise approved. 5. You shall avoid any conduct that is a violation of any law, municipal, or county ordinance. You may not associate with any criminals, substance abusers, or gang members. 6. You shall not change residence, employment, or phone number without permission from a Jail Supervisor. 7. You shall have your telephone operational at all times with no additional services (3-way calling, caller ID, call forwarding, or answering machine) that have not been approved by a Jail Supervisor. 8. You shall report as directed for scheduled and unscheduled appointments. 9. You shall not have alcohol in your residence or on your property, or use (consume, ingest, or take into my body) and drugs (legal or illegal) or alcohol that has not been prescribed by a physician. This includes all over the counter nonprescription medication and mouthwashes, which contain alcohol. You will be required to submit to scheduled and random chemical testing and/or urinalysis, at your expense. 10. You will not enter the premises of any bar or tavern. 11. Any Police contacts must be reported immediately to Jail Staff for forwarding to a Jail Supervisor. 12. You shall be subject to random home checks. You will allow anyone who comes to your home on behalf of the Sheriff s Department, permission to enter your home, to verify your compliance with program rules and conditions, and condition of program equipment. 13. Your schedule must be approved by a Jail Supervisor. Any changes in your schedule need prior approval 24 hours in advance. 14. You are responsible for informing any one at your residence about the program rules. NO extended or conjugal visits allowed. Only persons listed as a permanent resident on your initial application may stay overnight at your residence. 15. Initially, you will pay for two weeks in advance to initiate the program. You will then pay in advance the weekly fee, which is charged, for participation in the Electronic Monitoring Program. You will report to the Columbia County Jail once a week at scheduled times to make your fee payment and submit a work and appointment schedule. Your schedule must be for one week in advance. Your fees will be paid in cash or money orders. Personal checks will not be accepted. You will pay $ per week to offset the cost of the program and a $30.00 initial set-up fee. Failure to make payments as scheduled will result in your return to the Columbia County Jail. 16. You shall be held responsible for any damage to the equipment. You shall not tamper with, attempt, or allow anyone else to tamper with or attempt to fix the equipment. All equipment shall be returned to the Columbia County Jail at 403 Jackson St, Portage, WI (608) , upon termination of the program. If you do not bring the equipment back in good condition, the District Attorney can charge you with theft or vandalism. Page 1 of 2
2 17. You shall insure that your telephone and electricity expenses are paid for on time, disconnection is a violation. If your phone or electricity fail for any reason, you will report it immediately to the Columbia County Jail. 18. You may only disconnect or move the program equipment upon specific instruction from the Jail Staff. 19. You will place the Tracking Device in the Docking Station for a minimum of (10) ten hours per day and at all times while at home. 20. You will place the Tracking Device in its Docking Station immediately upon returning home. You will not remove the Tracking Device from the Station until you are authorized to leave the house for work. 21. You understand that all movement will be tracked and stored as an official record. 22. You will not enter areas that are defined as off-limits. 23. You agree to respond immediately to all messages that are sent to the MTD. 24. You are not allowed to submerge the bracelet into water. You are allowed to take a shower with the bracelet. 25. Other specific rules may be imposed at any time. It has been explained to you that any violation, while participating in the Columbia County Electronic Monitoring Program, may result in your immediate return to the jail. Your failure on this program may also result in the loss of Good Time and/or Huber privileges upon return to Jail. If you fail on this program, you will serve your remaining sentence at the Huber Center or the Jail. I agree that the County of Columbia, the Columbia County Sheriff s Department and its agents, are not liable for any damages incurred as a result of my participation in the program. I understand and do agree to abide by all of the conditions of this informed consent. Participant s Signature Date Signed Officer Signature Date Signed Elec Mont Rules.doc Page 2 of 2
3 COLUMBIA COUNTY SHERIFF S DEPARTMENT APPLICATION FOR ELECTRONIC MONITORING Applicant Name First MI Last Date of Birth File Number Social Security # Address How Long Lived At This Address City County Zip Code Telephone Number / Telephone Company / Sex Race Height Weight Eye Color Hair Color Scars/Marks/Tattoos Marital Status (Circle One) Married / Single / Divorced Do you rent or own? (Circle One) Rent / Own List ALL People Living With You: A. B. C. D. E. NAME AGE RELATIONSHIP Are you on Probation? YES / NO If yes, your Agent s Name What is the current charge(s) you are in Jail for? What is the length of your sentence? What is your scheduled begin date? Release date? Do you have any charges pending (List Charges)? Have you ever been convicted of a domestic charge? (Circle One) YES / NO If so, when? Victim Name Do you have any restraining orders or injunctions? Do you have special family circumstances we should know about? How is your health at this time? Are there weapons in your home? (Circle One) YES / NO If yes, location and type of weapons:
4 Do you have any disabilities or special medical conditions? Are you currently taking any prescribed medication(s)? (Circle One) YES / NO If yes, name of MEDICATION(S) Name of Doctor Phone # Have you ever been treated for drug or alcohol abuse? (Circle One) YES / NO If yes, location and reason for treatment Do you have regularly scheduled appointments besides work (i.e..treatment, counseling)? In the space provided give a short explanation as to why you should be eligible for this program: EMPLOYMENT INFORMATION Employer Address City County Phone # Type of Work Supervisor Name Phone # Weekly Work Hours (Days/Time) Length of Employment Does your job location vary? (Circle One) YES / NO Does your supervisor work on site with you? (Circle One) YES / NO Does your job take you out of the county? (Circle One) YES / NO Are you self employed (proof required)? (Circle One) YES / NO Will you have transportation that meets Huber requirement (i.e., valid DL, vehicle registration, etc.)? (Circle One) YES / NO Explain your transportation and how it meets Huber requirements: Applicant: ACCEPTED / DENIED Date: Reviewing Officer Signature:
5 COLUMBIA COUNTY SHERIFF S DEPARTMENT INMATE CONTRACT This contract constitutes the agreement made between the inmate and the Columbia County Jail for their role in the Electronic Monitoring Program. The undersigned inmate acknowledges a complete understanding of the rules and regulations of the Electronic Monitoring Program, and agrees to live within these rules and regulations. The inmate also pledges that all information given to the monitoring staff during the application and classification process is true to the best of their knowledge. The rules of the Electronic Monitoring Program have been provided to me. I fully understand what is expected of me and the possible consequences of my failure to comply with these rules. I agree to release the Columbia County Sheriff s Department, its personnel, and the vendor from any liability associated with my participation in the Electronic Monitoring Program. I understand that upon completion of the program, the equipment will be returned to the Columbia County Jail. I also must complete normal release from custody procedures at the Columbia County Jail on my release date. I am not allowed to remove my ankle strap at anytime. Jail Staff will remove the bracelet upon my release. My signature confirms the above as well as my receipt of the Electronic Monitoring Program equipment. INMATE NAME SIGNATURE DATE OFFICER SIGNATURE DATE
6 COLUMIBA COUNTY SHERIFF S DEPARTMENT Dennis Richards, Sheriff 711 E. Cook Street Portage, WI Office (608) Fax (608) EMPLOYER AGREEMENT will be participating in the Columbia County Jail Electronic Monitoring Program. The inmate will be enrolled in the program starting and ending. A requirement of this program is that the employer notify the Columbia County Huber Officer at (608) if the employee fails to report for work or leaves work during his/her assigned shift. The person on EMP may work up to six days a week. The responsibility for notification of shift changes or overtime rest with the employee who is on EMP and verified by the employer. The employee is required to contact the Jail Supervisor with schedule changes at least 24 hours in advance, and they are only allowed one schedule change per week. I agree to notify the Columbia County Jail/Huber Center of any violation. SUPERVISOR SIGNATURE Date COMPANY PHONE
FOND DU LAC COUNTY JAIL INFORMATION PACKET KEEP THESE ORANGE SHEETS FOR YOUR INFORMATION
FOND DU LAC COUNTY JAIL INFORMATION PACKET KEEP THESE ORANGE SHEETS FOR YOUR INFORMATION The Jail Rule book is provided in each living section for additional information You have been sentenced to the
More informationALLEGAN COUNTY SHERIFF S OFFICE/JAIL WORK RELEASE PROGRAM
ALLEGAN COUNTY SHERIFF S OFFICE/JAIL WORK RELEASE PROGRAM All applicants will be required to wear a GPS tether at all times while on work release. These tethers will be monitored daily for violations and
More informationRules of Release for Huber Inmates (Includes Child/Family Care, School Release and Community Service)
BAYFIELD COUNTY SHERIFF S DEPARTMENT JAIL DIVISION Rules of Release for Huber Inmates (Includes Child/Family Care, School Release and Community Service) - GENERAL RULES AND REGULATIONS - 1. You will be
More information3. Attorney s Statement: The licensed attorney must sign this statement. GENERAL
APPLICATION TO ENTER INSTITUTION AS THE REPRESENTATIVE OF A LICENSED ATTORNEY OR TO CORRESPOND WITH FEDERAL PRISONER AS THE REPRESENTATIVE OF A LICENSED ATTORNEY. This form has three parts: 1. Questionnaire:
More informationThis is very important for work release, self-employment, and childcare release.
Please review this packet. It contains information that you will need to know about serving your jail sentence. Once you have completed reviewing the information, call the Huber Sgt. to schedule an appointment
More informationTHE MANCHESTER FIRE ENGINE AND HOOK AND LADDER CO., NO.
THE MANCHESTER FIRE ENGINE AND HOOK AND LADDER CO., NO. 1 P.O. Box 416 - Manchester, MD 21102 Fire Calls: 911 Meeting Night: First Tuesday of each month Membership Fee: $5.00 / Year Date Application for
More informationVOLUNTEER APPLICATION
Thank you for your interest in Estes Park Medical Center. The mission of the Estes Park Medical Center is to make a positive difference in the health and wellbeing of all we serve. VOLUNTEER APPLICATION
More informationWithin this application package you will find the following forms and information:
Mechanicsville Volunteer Fire Department, Inc. Post Office Box 37 Mechanicsville, MD 20659-0037 Non Emergency: (301) 884-4709 / Emergency: Dial 9-1-1 www.mvfd.com Dear Membership Applicant: On behalf of
More informationMARATHON COUNTY JAIL HUBER RULES
MARATHON COUNTY JAIL HUBER RULES Sentenced Huber inmates granted work release status by classification will be allowed to exercise those privileges. It is the policy of the Marathon County Jail to operate
More informationELLICOTT CITY VOLUNTEER FIREMEN S ASSOCIATION, INC.
ELLICOTT CITY VOLUNTEER FIREMEN S ASSOCIATION, INC. APPLICATION FOR PROBATIONARY MEMBERSHIP Emergency ID# (assigned by LOSAP committee) (enter your 4 digit number if assigned one previously by Howard County)
More informationCOMPEER PROGRAM VOLUNTEER APPLICATION
Spreading Hope, Spurring Action, Supporting Families, Saving Lives! COMPEER PROGRAM VOLUNTEER APPLICATION 3701 Latrobe Drive, Suite 140 Charlotte, NC 28211 Phone 704.365.3454 Fax 704.365.9973 Revised 7/13/2017
More informationCarlisle Police Department Employment Application
Employment Application ADMINISTRATIVE ASSISTANT APPLICATION Carlisle Police Department 195 N. First Street Carlisle, IA 50047 (515)-989-4121 WAIVER I, agree to submit to written, physical agility, physical,
More informationPlymouth County Sheriff s Department. Application and Personal History Statement. Application. Please Print Clearly
Plymouth County Sheriff s Department Application and Personal History Statement Position applied for: Salary sought: Personal Application Please Print Clearly Date: Last: First: Middle: List your current
More informationC OMMUNITY, C OUNSELING, AND C ORRECTIONAL S ERVICES, I NC. WATCH West PROGRAM Visitor Application
C OMMUNITY, C OUNSELING, AND C ORRECTIONAL S ERVICES, I NC. WATCH West PROGRAM Visitor Application Please Print Any incorrect, incomplete, false or misleading information on this application will void
More informationBASIC REQUIREMENTS LAW ENFORCEMENT EXPLORER PROGRAM. Minimum 2.0 academic grade point average prior to and maintained after appointment.
BASIC REQUIREMENTS LAW ENFORCEMENT EXPLORER PROGRAM AGE: EDUCATION: PHYSICAL FITNESS: UNITED STATES CITIZENSHIP: Explorer / Cadet - Minimum Age 14 (Completed 8 th grade), or 15 years of age and not yet
More informationMission House Christian Transition House for Women
Mission House Christian Transition House for Women Purpose of the Home: Create a transitional program for women as the third step of recovery (Step 1 - Foundation development in a Christian safe house;
More informationGrand Prairie Fire Department Applicant Identification Form
Revised 07/15 Grand Prairie Fire Department Applicant Identification Form Place Picture Name: Last First Middle DOB: Weight: Height: Hair Color: Eye Color: Social Security No.: D.L. #: Complete the areas
More informationOUTAGAMIE COUNTY JAIL
OUTAGAMIE COUNTY JAIL Family/Visitor Informational Guide 320 S. Walnut Street Appleton, WI 54911 (920) 832-4449 Also available online at: www.outagamie.org 8 JAIL MINISTRIES The Chaplain at the Outagamie
More informationHave a car No pets Years of Experience
92 Thompson Road Avon, CT 06001 : (860) 357-5333 Fax: (860) 629-0858 Check all that apply: ID Card Driver s License US Passport Want Live-out CNA (State ) HHA Want Live-in Want Live-out Have a car No pets
More informationLompoc Police Department Explorer Post #700
Lompoc Police Department Explorer Post #700 APPPPLIICATIION FOR MEMBERSSHIIPP Print legibly all information required and answer all questions as completely and truthfully as possible. After filling out
More informationA Nine to Eighteen Month Residential Aftercare Program
APPLICATION Please Choose One: St. Louis Guest Homes Fort Good Shepherd Ranch Access to Recovery II referral: Yes No Please answer all questions honestly and completely. GENERAL INFORMATION Last Name First
More informationCarlisle Police Department Employment Application
Employment Application POLICE OFFICER APPLICATION Carlisle Police Department 195 N. First Street Carlisle, IA 50047 (515)-989-4121 CARLISLE POLICE DEPARTMENT Instruction for Applicants **Please do Not
More informationLast Name First Name M.I. Name You Prefer. City State Zip Address. Daytime Phone Evening Phone Best Time to Call. City State If yes, where?
GENERAL INFORMATION Last Name First Name M.I. Name You Prefer Mailing Address How long at this address? City State Zip County If less than a year, previous address How long have you resided in the county?
More informationMANAGER S BACKGROUND INVESTIGATION PACKET
CITY OF LAKEWOOD MANAGER S BACKGROUND INVESTIGATION PACKET Lakewood Civic Center The Lakewood Municipal code requires that, as a part of the amusement arcade license application, each individual who is
More informationVOLUNTEER & PROFESSIONAL SERVICES APPLICATION TRAVIS COUNTY SHERIFF S OFFICE Travis County Jail & Travis County Correctional Complex INSTRUCTION SHEET
VOLUNTEER & PROFESSIONAL SERVICES APPLICATION TRAVIS COUNTY SHERIFF S OFFICE Travis County Jail & Travis County Correctional Complex INSTRUCTION SHEET Thank you for your interest in being a volunteer or
More informationWILDWOOD CORRECTIONAL CENTER ELECTRONIC MONITORING PROGRAM
WILDWOOD CORRECTIONAL CENTER WHAT YOU SHOULD KNOW/WHAT IS EXPECTED OF YOU PROGRAM OVERVIEW: This program was not created for the convenience of inmates except to allow the offender to maintain employment,
More informationOUTAGAMIE COUNTY JAIL
OUTAGAMIE COUNTY JAIL Family/Visitor Informational Guide 320 S. Walnut Street Appleton, WI 54911 (920) 832-4449 Also available online at: www.outagamie.org TABLE OF CONTENTS Inmate Telephone System...
More informationCAUSE NO. THE STATE OF TEXAS IN THE DISTRICT COURT V. OF MONTGOMERY COUNTY, TEXAS
CAUSE NO. _ THE STATE OF TEXAS IN THE DISTRICT COURT V. OF MONTGOMERY COUNTY, TEXAS DEFENDANT _ JUDICIAL DISTRICT MONTGOMERY COUNTY VETERANS TREATMENT COURT PROGRAM PARTICIPANT CONTRACT Name: Address:
More informationMacon County Mental Health Court. Participant Handbook & Participation Agreement
Macon County Mental Health Court Participant Handbook & Participation Agreement 1 Table of Contents Introduction...3 Program Description.3 Assessment and Enrollment Process....4 Confidentiality..4 Team
More informationState of North Carolina Department of Correction Division of Prisons
State of North Carolina Department of Correction Division of Prisons POLICY & PROCEDURES Chapter: F Section:.0400 Title: Emergency Leave Issue Date: 10/03/05 Supersedes: 08/26/02.0401 General This policy
More informationFelony Mental Health Court Success Through Addiction Recovery Drug Court Program Veterans Court
CAUSE NO. The State of Texas In the District Court v. of Harris County, Texas Defendant Judicial District HARRIS COUNTY SPECIALTY COURT PROGRAM PARTICIPANT CONTRACT Name: DOB: _ Address: Cell No: _ Email:
More informationEast Baton Rouge Parish Junior Deputy
East Baton Rouge Parish Junior Deputy 2018 Application Packet Sheriff Sid J. Gautreaux, III Captain Randy M. Aguillard Program Director raguillard@ebrso.org Junior Deputy Membership Rules All members of
More informationMANAGER S REGISTRATION/CHANGE FORM HOTEL & RESTAURANT, TAVERN, CLUB OR ARTS LIQUOR LICENSE
CITY OF LAKEWOOD MANAGER S REGISTRATION/CHANGE FORM HOTEL & RESTAURANT, TAVERN, CLUB OR ARTS LIQUOR LICENSE Colorado Revised Statutes require Hotel & Restaurant and Tavern licenses to have a separate and
More informationCOUNTY OF SACRAMENTO Probation Department
COUNTY OF SACRAMENTO Probation Department 9750 BUSINESS PARK DRIVE, SUITE 220, SACRAMENTO, CALIFORNIA 95827 TELEPHONE (916) 875-0273 FAX (916) 875-0347 LEE SEALE CHIEF PROBATION OFFICER COUNTY PAROLE OFFICER
More informationSign and return included forms. (Authorization to Release Information Form, Background Check Form and Vehicle Use Agreement)
To: Employees with Conditional Offers of Employment Re: Background Checks All offers of employment or participation in any activity involving minors in a University sponsored program with The University
More informationPresent Address Telephone ( ) Street City State Zip. Permanent Address Telephone ( ) Social Security Number / / address
Application for Classified Personnel Minden Public Schools An Equal Opportunity/Affirmative Action Employer 543 West Third Phone: (308) 832-2440 Minden, NE 68959 Fax: (308) 832-2567 Please type or print
More informationCOUNTY OF SACRAMENTO Probation Department 3201 FLORIN-PERKINS ROAD, SACRAMENTO, CALIFORNIA TELEPHONE (916) FAX (916)
RULES AND REGULATIONS The Ride-Along Program offers members of the public the opportunity to interact with officers from our Department. The program seeks to increase public awareness regarding the functions
More informationRIVER CITY ADVOCACY COUNSELING SERVICES 145 Landa Street New Braunfels, TX (830)
Date / / Client information: First name Middle initial Last name Parent/Legal Guardian (for 17 and under) Address Phone number Home Wk Cell Date of birth / / Sex Marital Status Ethnicity Employment status:
More informationCODE OF MARYLAND REGULATIONS (COMAR)
CODE OF MARYLAND REGULATIONS (COMAR) Title 12 DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES Subtitle 10 CORRECTIONAL TRAINING COMMISSION Chapter 01 General Regulations Authority: Correctional Services
More informationIN THE SUPERIOR COURT OF CHATHAM COUNTY STATE OF GEORGIA SAVANNAH-CHATHAM COUNTY DRUG COURT CONTRACT
IN THE SUPERIOR COURT OF CHATHAM COUNTY STATE OF GEORGIA STATE OF GEORGIA vs. Case No., Defendant SAVANNAH-CHATHAM COUNTY DRUG COURT CONTRACT You are voluntarily entering the Savannah-Chatham County Drug
More informationVolunteer Application
Volunteer Application Thank you for your generosity. The time and energy of our volunteers make Women and Children s Horizons effective for survivors and victims of sexual and domestic abuse. Please complete
More informationYOUTH FOR TOMORROW NEW LIFE CENTER
APPLICATION N YOUTH FOR TOMORROW NEW LIFE CENTER CHRISTIAN ACADEMCY AND THERAPEUTIC BOARDING SCHOOL 2016-2017 Revised 7/1/2016 Child s Name: Step 1 Application Process Date Once we receive all of the information
More information2016 Multi-Jurisdictional Law Enforcement Explorer Academy
2016 Multi-Jurisdictional Law Enforcement Explorer Academy All questions must be answered. If something does not apply please indicate N/A. Note: If there are any un-answered questions on this application
More informationGLYNN COUNTY SHERIFF S OFFICE IS AN EQUAL OPPORTUNITY EMPLOYER
100 Sulphur Springs Road Brunswick, GA 31520 Telephone: (912) 554-7600 Web Page Address: www.glynncountysheriff.org INSTRUCTIONS AND INFORMATION PLEASE READ CAREFULLY BEFORE BEGINNING 1. Please complete
More informationCODE OF MARYLAND REGULATIONS (COMAR)
CODE OF MARYLAND REGULATIONS (COMAR) Title 12 DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES Subtitle 10 CORRECTIONAL TRAINING COMMISSION Chapter 01 General Regulations Authority: Correctional Services
More informationPolk County Sheriff s Office
Polk County Sheriff s Office Explorer Post 900 Application Grady Judd, Sheriff Polk County Sheriff s Office 1891 Jim Keene Blvd Winter Haven, FL 33880 (863) 298-6200 www.polksheriff.org Pride In Service
More informationBasic Information. Date: Patient s Name: Address:
1 Basic Information : Patient s Name: Address: Home Phone: Work Phone: Cell Phone: Email: Age: Birth : Marital Status: Occupation: Educational History: Name, Address and Phone of Child s School Counselor
More informationSACRAMENTO COUNTY SHERIFF S DEPARTMENT SCOTT R. JONES Sheriff. Volunteer Packet
SCOTT R. JONES Sheriff Volunteer Packet VIPS (Volunteers In Partnership with the Sheriff) DART (Dive And Rescue Team) SAR (Search And Rescue) SHARP (Sheriff s Amateur Ham Radio Program) Sacramento Sheriff
More informationRutherford Co. Rescue
RCLAFA, INC. Rutherford Co. Rescue Application You are only allowed to check one that you are applying for: Reserve Status Specialty Rescue Team Part-Time Paid Employee This application must be completely
More informationCITY OF GLENDALE APPLICATION FOR POLICE OFFICER CHECK LIST
CITY OF GLENDALE APPLICATION FOR POLICE OFFICER CHECK LIST Be a U.S. Citizen. To apply you must: Have never been convicted of a felony (unless pardoned) Ability to lawfully possess a firearm Prior to appointment
More informationCOMMUNITY, COUNSELING & CORRECTIONAL SERVICES, INC. Gallatin County Re-Entry Program SPONSOR FORM
COMMUNITY, COUNSELING & CORRECTIONAL SERVICES, INC. Gallatin County Re-Entry Program SPONSOR FORM Name of Resident Being Sponsored: Name of Sponsor Applicant: Community passes are one of the most important
More informationVolunteer Application
Volunteer Application VOLUNTEER INTEREST (Please Write Legibly) Mounted Patrol Reserve Deputy Water Recovery Unit Chaplain Corps Explorer Post Jail Programs APPLICANT INFORMATION Last Name First M.I. Date
More informationLIBERTY DENTAL PLAN. Dental Hygienist - Credentialing Application. City: State: DEGREE: City: State: DEGREE:
*Required Fields LIBERTY DENTAL PLAN Dental Hygienist - Credentialing Application Please complete one application per Dental Hygienist Demographic Information: Male Female *HYGIENIST NAME: RDH Other *DATE
More informationHAMILTON COUNTY SHERIFF S OFFICE SPECIAL DEPUTY APPLICATION
HAMILTON COUNTY SHERIFF S OFFICE SPECIAL DEPUTY APPLICATION The classification of Special Deputy is a voluntary, non-compensated position affiliated with the Sheriff s Office and requires the individual
More informationCommunity Emergency Response Team (CERT) Volunteer Application Douglas County Citizen Corps Council Douglas County Sheriff s Office
Community Emergency Response Team (CERT) Volunteer Application Douglas County Citizen Corps Council Douglas County Sheriff s Office PLEASE TYPE OR PRINT FULLY ANSWER ALL QUESTIONS USE INK ONLY An Incomplete
More informationEMPLOYMENT PROCEDURES FOR PARAPROFESSIONAL STAFF
EMPLOYMENT PROCEDURES FOR PARAPROFESSIONAL STAFF PHASE I 1. Secure application form in person, mail, telephone, or website (www.pittsville.k12.wi.us). 2. Return the completed application form with a copy
More informationUMATILLA COUNTY EMPLOYMENT APPLICATION
DATE/TIME APPLICATION RECEIVED: BY: UMATILLA COUNTY EMPLOYMENT APPLICATION AN EQUAL OPPORTUNITY EMPLOYER REVISED 01/17 Human Resources Department Umatilla County Courthouse 216 SE 4 th Street, Pendleton,
More informationMental. Health. Court. Handbook
Mental Health Court Handbook Introduction/Eligibility The 8 th Circuit Court Mental Health Court is for people who have been convicted of a crime and have mental health issues suggesting a need for comprehensive
More informationMassage Therapist License Application W 87 Street Pkwy Phone Lenexa, KS Fax
Massage Therapist License Application 17101 W 87 Street Pkwy Phone 913-477-7725 Lenexa, KS 66109 Fax 913-477-7730 www.lenexa.com NOTE: Any failure to fully or truthfully answer any question or provide
More informationGilmer Independent School District 500 So. Trinity Gilmer, Texas Phone: (903) FAX: (903)
Gilmer Independent School District 500 So. Trinity Gilmer, Texas 75644 Phone: (903) 841-7400 FAX: (903) 843-5279 Employment Application for Professional Personnel POSITION (S) FOR WHICH YOU ARE APPLYING:
More informationNetwork Participant Credentialing Application
Please: Type or print legibly Complete all items. If an item does not apply, enter NA. Do not leave any items blank. Include the following with your application, if applicable: Copy of professional license(s)
More informationPlease complete this application by pen (print) or typewriter in its entirety. PERSONAL INFORMATION. First MI Last. Street City State Zip
Qualified applicants are considered for all positions without regard to race, color, religion, gender, national origin, age, covered veteran's status, marital status, or the presence of a non-job-related
More informationFiler Police Department 300 Main Street Office: P.O. Box 140 Dispatch: Filer, Idaho Fax:
Filer Police Department 300 Main Street Office: 208 326-4123 P.O. Box 140 Dispatch: 208 735-1911 Filer, Idaho 83328 Fax: 208 326-5004 www.cityoffiler.com 911 Emergency EQUAL OPPORTUNITY EMPLOYER Prospective
More informationIndiana Energy Assistance Program Application Part 1. Personal Information
INSERT AGENCY LOGO 2017-2018 Indiana Energy Assistance Program Application Part 1. Personal Information Your Name Date of Birth First MI Last Social Security Number MM-DD-YYYY Current Home Address: Street
More informationVERMILLION COUNTY SHERIFF'S OFFICE
VERMILLION COUNTY SHERIFF'S OFFICE Michael R. Phelps - Sheriff 1888 S State Rd 63 - P.O. Box 130 Newport, IN 47966 (765) 492-3737 / 492-3838 (Fax) 492-5011 sheriff@vcsheriff.com Employment applications
More informationLIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( )
(Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:
More informationMONROE COUNTY SHERIFF S OFFICE APPLICANT INFORMATION SUMMARY
Name (print or type): Date Received Position Applied For: by MCSO: MONROE COUNTY SHERIFF S OFFICE APPLICANT INFORMATION SUMMARY INTEGRITY RESPECT SERVICE DIVERSITY HONOR STATEMENT OF EQUAL EMPLOYMENT OPPORTUNITY
More informationKittanning Volunteer Fire Departments 1-4-6
Kittanning Volunteer Fire Departments 1-4-6 APPLICATION FOR MEMBERSHIP Kittanning Hose, Hook & Ladder Company Number 1 Kittanning Volunteer Fire Department Number 4 Kittanning Hose Company Number 6 Applicants
More informationCITY OF MADISON HEIGHTS OFFICE OF THE CITY CLERK BUSINESS LICENSE INITIAL APPLICATION
CITY OF MADISON HEIGHTS OFFICE OF THE CITY CLERK BUSINESS LICENSE INITIAL APPLICATION I (we) the undersigned do hereby apply and petition the City of Madison Heights to license the following business establishment.
More informationInitials of State and Out of State DL # Complete as Applicable
Bridgeway Center Inc. Community & Court Education Services Enrollment Form Have you ever attended any classes at Bridgeway Center, Inc.? Yes No Today s Date First Name Middle Name Last Name / / Address
More informationWATCH ME GROW FAMILY REGISTRATION FORM SHEET 1 OF 6
WATCH ME GROW FAMILY REGISTRATION FORM SHEET 1 OF 6 Parent/Guardian Information Registration Mother/Guardian First Name: M.I. Last Name: Date of Birth: Address (please include city, state and zip code):
More informationREFERENCES: (If applying to assist with religious activities, please include a member of the clergy as a reference.)
BRRJA APPLICATION FOR VOLUNTEER SERVICES SITE: AA NA Academic Religious Other DATE: FULL NAME: Last First Middle HOME ADDRESS: Street City State Zip PHONE: Home Cell Work EMAIL ADDRESS: EDUCATION: HS Degree
More informationLast Name First Middle Initial Maiden Name (if applicable)
Application For Sheriff Deputy Employment PLEASE PRINT IN INK OR TYPE Marinette County Human Resources 1926 Hall Avenue Marinette, WI 54143-1717 Marinette County is an equal opportunity employer. All hiring,
More informationSHERIFF OF GARFIELD COUNTY LOU VALLARIO
SHERIFF OF GARFIELD COUNTY LOU VALLARIO 107 8 TH Street Glenwood Springs, CO 81601 Phone: 970-945-0453 Fax: 970-945-7700 106 County Road 333-A Rifle, CO 81650 Phone: 970-665-0200 Fax: 970-665-0253 Dear
More informationQuakertown Fire Company, Pittstown, NJ. Franklin Township Fire District No. 1 of Hunterdon County
Quakertown Fire Company, Pittstown, NJ Application for Active Membership Franklin Township Fire District No. 1 of Hunterdon County Release and Consent Form authorizing the Franklin Township Fire District
More informationHIPAA THE PRIVACY RULE
HIPAA THE PRIVACY RULE Reviewed December 2012 HISTORY In 2000, many patients that were newly diagnosed with depression received free samples of antidepressant medications in their mail. 2 HISTORY Many
More informationPlease note: Assistance filling out the FAFSA is available. Please ask for more information.
HOUSING College Housing Assistance Program Application THA Form (#) REM-CHP-01 You must be an enrolled T.C.C. student registered for or attending classes to participate in this program. Please complete
More informationINFORMED CONSENT FOR TREATMENT
INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care
More informationNOTICE DEPUTY SHERIFF APPLICANTS
Waivers NOTICE DEPUTY SHERIFF APPLICANTS All applicants for the position of Deputy Sheriff should be aware of the following Georgia statute: O.C.G.A. 35-8-22, Reimbursement of training expenses by subsequent
More informationALBANY POLICE CADET APPLICATION
ALBANY POLICE CADET APPLICATION We are pleased that you are interested in the Albany Police Department Cadet Program. The Cadet Program affords young men and women the opportunity to become involved with
More informationRESERVE DEPUTY SHERIFF APPLICATION WHAT IS A RESERVE DEPUTY SHERIFF?
RESERVE DEPUTY SHERIFF APPLICATION Qualifications to Join the Oklahoma County Reserve Deputy Program include: Be a U.S. Citizen; Be at least 21 years of age at the time of appointment; Be a high school
More informationAlbuquerque Police Department Applicant Additional Documents. Name: Page 1 of 9
Albuquerque Police Department Applicant Additional Documents Name: Page 1 of 9 Additional Documents Needed Instructions You will need to locate/gather all of the following documents and bring them with
More informationAdventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission:
Adventure Club Before and After School Care Enrollment Packet Before and After School Care Mission: Our before and after school care is designed to provide children with a safe, loving and exciting environment
More informationName of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip
SCHNEIDER REGIONAL MEDICAL CENTER 9048 SUGAR ESTATE ST. THOMAS, U.S.V.I 00802 APPLICATION FOR TEMPORARY PRIVILEGES (USED FOR URGENT PATIENT NEED AND LOCUM TENENS) COMPLETE THE APPLICATION IN FULL. PRINT
More informationNON-TEACHING APPLICATION
WA-NEE COMMUNITY SCHOOLS 1300 North Main Street Nappanee, IN 46550-1015 For Office Use Only Interview (date & time) Reference Check Expanded Criminal Background Check Drug Test Sexual Offender Check CPS
More informationYMCA OF MIDDLE TENNESSEE AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT
YMCA OF MIDDLE TENNESSEE AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF A CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT *This information will be used for verification and identification purposes only
More informationJefferson County Sheriff s Office 200 Courthouse Way, Rigby, ID PH# ~ FX#
Jefferson County Sheriff s Office 200 Courthouse Way, Rigby, ID 83442 PH# 208-745-9210 ~ FX# 208-745-9212 JOB APPLICATION Name: Application Date POSITION APPLIED FOR: Patrol Jail Dispatch Reserve Application
More informationMatlacha/Pine Island Fire Control District 5700 Pine Island Road Bokeelia, FL APPLICATION FOR EMPLOYMENT
Position(s) Applied For Matlacha/Pine Island Fire Control District 5700 Pine Island Road Bokeelia, FL 33922 APPLICATION FOR EMPLOYMENT Date of Application PERSONAL INFORMATION Last Name First Name Middle
More informationWashington County Tennessee Sheriff s Office. Ed Graybeal, Sheriff. Employment Application Packet
Washington County Tennessee Sheriff s Office Ed Graybeal, Sheriff Employment Application Packet PLEASE READ CAREFULLY AND ANSWER ALL QUESTIONS COMPLETELY. INCLUDE A COPY OF YOUR DRIVER S LICENSE, BIRTH
More informationEMPLOYEE INJURY REPORTING PROCEDURE
Updated 12/1/2015 TDY MEDICAL STAFFING, Inc. EMPLOYEE INJURY REPORTING PROCEDURE STEP 1: IS INJURY LIFE THREATENING/EMERGENCY? Call 911/go to ER if yes. STEP 2: CALL CLAIM INTO TDY 215-736-5147 STEP 3:
More informationCalhoun County Sheriff s Office. Sheriff Thomas Summers Jr. Employment Application
Name: Calhoun County Sheriff s Office Sheriff Thomas Summers Jr. Employment Application Equal Opportunity Employer 2811 Old Belleville Road (PO Box 749) St. Matthews, SC 29135 803-874-2741 www.calhounscsheriff.com
More informationCherokee County Fire & Emergency Services
Cherokee County Fire & Emergency Services Application for the Position of: VOLUNTEER SERVICE REV.9/2010 CHEROKEE COUNTY FIRE & EMERGENCY SERVICES 150 Chattin Drive, Canton, GA 30115 678-493-4000 (phone)
More informationCamper Information, Waiver & Release Forms
Camper Information, Waiver & Release Forms 1. MEDICAL INFORMATION: Does the camper have any special dietary needs? Yes No (If yes, please explain) Does the camper have any allergies? Yes No (If yes, please
More informationTHE COUNSELING PLACE ADULT INTAKE FORM Yearly Family Income:
Person to Contact in Case of Emergency Name Relationship Best Contact Number Alternative Contact Number Office Use Only Intake Date Reason for referral Counselor THE COUNSELING PLACE ADULT INTAKE FORM
More informationVolunteer Application Packet
Volunteer Application Packet Thank you for your interest in the TechTutor Volunteer Program. This Application Packet contains the Application Checklist, and Request for Criminal History & Disclosure forms.
More informationProfessional Credential Services, Inc.
Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Licensure Application for Occupational Therapists For the Massachusetts Board of Allied Health Professionals
More informationApplication Process. Payment Options: a) Pay in Full: $200 registration fee due with Police Academy application. Balance $4,000 due by orientation.
Application Process Application Part I 1) Complete Application Part I (below) at any time for the upcoming academies and return it with a $200 non-refundable registration fee. The registration fee will
More informationI. AUTHORITY APPLICABILITY
STATE OF OHIO SUBJECT: PAGE 1 OF 10 Inmate Visitation NUMBER: 76-VIS-01 RULE/CODE REFERENCE: SUPERSEDES: 76-VIS-01 dated 02/12/06 RELATED ACA STANDARDS: EFFECTIVE DATE: 4-4498, 4-4499, 4-4499-1, 4-4500,
More information1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY
2016-17 South Carolina 4-H Membership and Event Permission Form for Youth (Updated 08.01.16) ALL elements of this form must be completed by youth participating in clubs, field trips, events requiring group
More informationClayton County Sheriff s Office Internship / Volunteer Program S.O.I.P. Sheriff s Office Internship Program
Clayton County Sheriff s Office Internship / Volunteer Program S.O.I.P. Sheriff s Office Internship Program 1 Clayton County Sheriff s Office Internship Program PACKAGE TABLE OF CONTENTS Topic Page(s):
More information